Download Topical Steroid Workshop

Topical Steroid Therapy
Val Anderson
Dermatology Specialist Nurse
South Gloucestershire Community
Health Services
What are steroids?
• Essentially hormones
• Glucocorticoids/ mineralcorticoids
• Naturally formed in the adrenal cortex
• Natural glucocorticoids maintain normal
blood sugar and assist the body to recover
in times of stress.
Why Topical Steroids ?
• To gain control of signs and symptoms of
inflammatory skin disease
• Achieve maximum efficacy with minimal
side effects.
Action of Topical Steroids
• Anti-inflammatory
• Immunosuppressive
• Vasoconstrictive
• Anti-mitotic – decrease proliferation
• Readily penetrate the dermis
“Reduce inflammation and make the skin less sore and itchy”
Steroid Phobia
• Present in health care professionals,
patients and carers.
• A reluctance to use prescribed topical
steroids due to perceived side effects
• Reassurance is essential to gain full
concordance with treatment.
REMEMBER: Appropriate topical steroid use
limits potential side effects almost entirely.
Potential side effects
Cutaneous
Thinning / Atrophy
Hypopigmentation
Striae
Telangietasia
Tachyphylaxis,
Infections,
Perioral dermatitis,
Contact dermatitis,
Hirsutism,
Monomorphic acne or rosacea
N.B
Epidermal thinning does occur within 1-3 weeks of tx with potent or
very potent steroids normal skin but reverses within 4 weeks of stopping
Potential Side Effects : systemic
• These are RARE and ALWAYS AVOIDABLE
• Due to systemic absorption of the steroid
Adverse effects : systemically
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Osteoporosis
Muscle atrophy
Cushings Syndrome
Inhibition of growth (children)
Cataracts
Masking of infection
Hypoglycaemia
Which steroid?- factors to consider
• Age /potency – adult, adolescent or child
• Site – absorption increased at certain sites
• Extent- localised or generalised
• Base- creams or ointments?
• Method- frequency of application /
occlusion
• Experience of use - dexterity
Steroid potencies
• Group I.
• Group II.
• Group III.
• Group IV.
Mild e.g. Hydrocortisone 1% OTC (over the counter)
Mod (1 X OTC)
Potent  prescription only
Very potent  prescription only
Relative potencies compared to Hydrocortisone 1% (Grp I)
• Group 2 - 2.5 x stronger
• Group 3 - 10 x stronger
• Group 4 - 50 x stronger
Steroid ladder
VERY POTENT
 Dermovate
 Nerisone Forte
POTENT
 Synalar
 Fucibet
 Diprosalic
 Betnovate
 Elocon
 Locoid
MODERATELY
POTENT
 Eumovate
 Haelan
 Trimovate
 Calmurid HC
 Betnovate RD
 Synalar 1 in 4
MILD
 Hydrocortisone
0.5%,1.0% & 2.5%
 Fucidin H
 Alphosyl HC
 Synalar 1 in 10
Steroid application
• Reassure - explain rationale for use and benefits
• Early use - to control exacerbations
• Therapeutic dose - < prolongs flare and subsequent control
• Demonstrate - light smear, F.T.U (finger tip unit)
Weekly Quantities of steroid
Adult using b.d applications
Creams and Ointments
• face & neck…………………… 15 - 30g
• both hands…………………… 15 - 30g
• scalp………………………….. 15 - 30g
• both arms…………………….. 30 - 60g
• both legs……………………… 100g
• trunk…………………………... 100g
• groins & genitalia……………. 15 - 30g
BNF March 2006
Summary of NICE Guidelines
• No statistical difference between once and
twice daily steroid applicaton frequency on
efficacy.
• Application 10-14 days and consider
steroid holiday
• Improve patient and carer education
Steroid Workshop
•Practice finger tip unit measurements
•Discuss photos and case studies
Case Study 1
• 6 month old baby with history of eczema since 4
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months old.
Tried emollients and has been given topical
steroids by GP 2 weeks ago.
O/E moderate eczema present on facial cheeks.
Excoriations present and baby waking at night.
Not improved since prescription for topical
steroid given.
What issues related to topical
steroid use would you
consider during assessment
and treatment decisions for
this child ?
Case Study 2
• 14 year old boy
• History of eczema since 2 years old.
• O/E has moderate levels of eczema in arm
flexures with some weeping.
• Prescribed hydrocortisone 1% ointment by
GP 3 weeks ago- nil improvement.
• Arms now becoming sore.
What issues related to topical
steroid use would you
consider during assessment
and treatment decisions for
this child ?
Any Questions ?
I have one for you
What will you do differently
tomorrow?